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Date run 9/5/2014 1:51:44PM SAN JOA6F I COUNTY ENVIRONMENTAL HEALI., Report 5021 <br /> Run by Pagel <br /> Facility Information as of 9/5/20 <br /> Record Selection Criteria: Facility ID FA0018251 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN Tax ID . <br /> Owner ID OW0017589 New Owner ID : <br /> Owner Name {rI@Hb-. HER K U L.V I /'j S .Owner DBA DBA SUBWAY SANDWICHES& SALAD <br /> Owner Address 5'QS' .� I(J}P 0&Y COURT <br /> S 06fET 4-C� 9�2^,2 D'�s ! hTNRODI C A 115330 <br /> Home Phone 2$93z^3 v8G3 20 1. 232- 'ISS7 <br /> Work/Business Phone 209-887-2220 <br /> Mailing Address 4&52 TI LDOR Rg�S Fti gae FlLA'(2n1EY COL/e-T <br /> STkG4ffeN, X5'2 LN-T CA GS33o <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0018251 10186829 <br /> Facility Name SUBWAY SANDWICHES & SALAD <br /> Location 18754 E HWY 26 <br /> LINDEN, CA 95236 <br /> Phone 209-366-3691 <br /> Mailing Address _4&52_TbEyC)RjRCrSE-GTE-N— r—IQAP_ _5�Y coup--r <br /> CA7N2(DR (A 'Y93 3 0 <br /> Care of -S+DttU- <br /> ,reN- (>(_Y <br /> Location Code 99-UNINCORPORATED P Alt Phone <br /> BOB District 004-VOGEL, KEN Fax <br /> APN 10517048 EMail: CaREP«SIJbS°I Z d1V NdD.Cc1 v( <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION PAYMENT y <br /> Contact Name—S0HU-Hf (�tSSf�c- <br /> Title <br /> Day Phone ?z�_66-.'+vo-1-• S'EP Q 5 �V'") 2UC(- g87-2z2o <br /> NightPhonarL,0S-887-_= OUNrY 2oc1_ 232 - <br /> ACCOUNTS RECEIVABLE FILE INFORMATION SAN JOAOUI <br /> ENVIROME <br /> NTAL <br /> DEPARTMENT <br /> Account ID AR0032123 HEA►-TH New iii t ID: <br /> Mail Invoices to Facility Mail Invoices to: Is Facility / Account <br /> Account Name SUBWAY SANDWICHES &SALAD (clrcleOne) <br /> Account Balance as of 9/5/2014: $0.00 <br /> (Circle One) <br /> Transferto ActivennaMe <br /> ProgramfElement and Desorption Record 10 Employee ID and Name Status New Omen Delete <br /> ESTAURANT/BAR 21-50 SEATS PRO526939 EE0008999-LEYNA HUYNH Active Y N A I D <br /> 1 -HMBP-Regular-Primary Location PRO536820 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0536844 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all Bite,and'or project specific,PHS'EHD hourly charges associated with this facility <br /> oractiviy,will be billed to the parry Identified as the OWNER on this term. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes anNor Standards and State anNor <br /> Federal Lam. <br /> APPLICANTS SIGNATURE: Y— L�C7S `�-- Date <br /> Program Records to be T,�RANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Pai Da Date .' <br /> Payment Type V Check Number Z Received b <br /> REHS: /1/1- / Crh Date S ! I(V Account out: Date�/ S I <br /> COMMENTS: <br /> J (.wv�Z559/2 <br />